Introduction

Patient autonomy and right to refuse treatment have long been subjects of much controversy throughout the world. Many authors advocate that the patient could use this autonomy at the expense of his or her life (₁,₂,₃). There is no doubt that personal beliefs and lifestyles deserve to be fully respected. On the other hand, decisions reached under the guidance of these beliefs could face difficulties in some instances. In time, countries adopt changes in legal system mandated by their social characteristics.

A classical example is that the age of a person sought for to get married vary between 16 and 18 (¹,²,₄). Likewise, attitudes toward healthcare needs also change in accord with social features. In countries with Muslim majority it is common to see patients rejecting injections and other procedures in the context of religious fasting, whereas refusal of transfusion by a Jehovah's Witness facing a life threat is rarely encountered. Jehovah's Witnesses represent a special population in terms of refusal of a specific mode of treatment, namely blood transfusion. Nonetheless, in general terms, the Jehovah's Witness patient has a right to refuse blood, and the health care team is obligated to abstain from administering transfusions.

In this report we describe the clinical course of a patient who refused blood transfusion despite multiple serious stab wounds. It is one of the few cases whose resuscitation needs had to be tailored after rejection of transfusion in presence of a life-threatening trauma (₅,₆). The responsible physician had to perform resuscitation without blood transfusion; mainly with normal saline. Practical aspects of patient autonomy and right to refuse treatment in Turkey will be discussed as well as the current situation delineated by the laws and other regulations.

Case Report

Forty-four year-old Turkish woman is brought to the nearby University Emergency Department (ED) by private taxi at 20.40. The patient has no significant medical history except myoma uteri and is learned to have marital problems which had led to a quarrel resulting in multiple stabbing wounds by her husband.

On presentation, her vital signs are normal with intact consciousness. Physical examination reveals a through-and-through laceration of 4 cm in right cheek. This lesion causes profuse intraoral bleeding and seventh cranial nerve paralysis. All lacerations and relevant features are described in Table I.

Figure 1

Table I. Lacerations and significant features.

Intravenous (IV) normal saline infusion is administered via two large-bore IV lines and oxygen 4 l/min is started besides with cardiac monitoring. Her blood type is A Rh-positive and hemoglobin level is 10.2 gr/dl and hematocrit 32%. Other blood count and biochemistry disclose no abnormalities. Radiological investigations are also interpreted as normal. The laceration on the right cheek is repaired rapidly to stop the bleeding which threatened the airway patency.

As soon as the patient is admitted to the ED the patient and relatives declare that they refuse to receive blood transfusion as she is one of the Jehovah's Witnesses. She also carries a signed declaration on refusal of transfusion of blood and products. For this reason, no blood is transfused and the whole resuscitation is carried out with normal saline. Thoracic surgery, plastic surgery, otorhinolaryngology and orthopedic surgery are consulted. Orthopedic surgeons recommend the patient to be operated on to repair tendon lacerations while otorhinolaryngologists also plan to operate on the buccal laceration.

The patient receives 5500 ml normal saline in 3 hours and the urinary output is 3250 in the meantime.

Amoxicillin-clavunate (1.2 gr) is administered intravenously. The patient is alert during the resuscitation and free of any sign indicating impaired vital organ perfusion. At 22.30, hemoglobin level is 5.6 gr/dl and hematocrit 18.8%. The patient has to be transferred to social security hospital due to insurance coverage issues coupled with lack of beds. At 00.45 the patient is transported to another facility in stable condition accompanied by paramedic personnel. At this hospital she undergoes repair of the nerve injury on the left hand. The patient turned down blood transfusion in this hospital, and therefore received only crystalloid fluids. She was discharged without any sequelae after three uneventful days. When the authors called her after two years, the patient was alive and divorced from her husband at the time of injury.

Discussion

The patient's right to consent or refuse is derived from the principle of autonomy. Autonomy concept could be thought as a right to self-determination or the participation of individual to all decisions about his/her health. Autonomy is the capacity to make deliberated or reasoned decisions for oneself and to act on the basis of such decisions. Respect for people's autonomy is an important moral principle or value that is widely agreed those involved in health care need to consider. It grounds to such ethical concerns as the obligation to obtain informed consent from patients before doing things to them (₇). Informed consent is a moral duty to provide sufficient information for a patient to make an informed and rational choice whether or not to consent to a medical procedure (₈). These rights are also regulated by means of national and international legislations. Lisbon Declaration of World Medical Association which was published in 1981 include a statement that “Patients have the right to accept or refuse the treatment provided with due information” (⁴,₉).

To obtain informed consent could be seen just as obtaining a signed form from patient. But in fact, the diagnosis and treatment modalities, expected benefits, complications, alternative pathways in management, and the features of these methods should be explained to the patient (₁₀). In addition, the patient must understand and evaluate the information to consent or refuse. The fundamental elements for a valid informed consent process include disclosure, comprehension, voluntariness, competence, and consent (₁₁).

In this case, the patient was competent, and fully informed about her situation. She has refused the treatment because of her religious belief, and she has stated that she accepted all possible outcomes. In addition, she holds a card that indicated absolute refusal of blood transfusion. Migden et al suggested that although the card claims to refuse blood, emergency physicians should look for evidence of an ‘informed' refusal when evaluating these documents (₁₂).

The ethical dilemma that a physician could face is his professional obligation to preserve life as much as possible while he has to respect the personal autonomy. In this situation, some physicians think that life is the most valuable thing, the primary responsibility of a physician is to save his/her patient's life, and that only a physician is able to make a decision about what is good for the patient, and a patient must be treated despite his/her wishes. This paternalistic approach is widely supported in our society. In a research that has been carried out in a metropolis, it has been found that most of the patients thought the physician had a right to make a decision without asking their wishes (%80.9), and half of the patients stated that they would not refuse the treatment even if it is not the way that they have permitted (₁₃). But if the patient is competent and refuses the treatment as in this case, the only thing that a physician could do is to respect his/her patient's decision, and to continue to the treatment as the way he/she accepted. According to the Constitutional Chart, the physician's duty to respect the Jehovah's Witness' refusal of blood transfusions is absolute in order to avoid any treatment that is in conflict with the religious faith that each patient is free to profess (³). Nevertheless, doctors worldwide have come to respect their conscientious stand on blood and many doctors have successfully invented and applied techniques of bloodless surgery.

A Turkish legislation dating back to 1928 emphasized that “access to treatment is a right of the patient. He or she may choose to demand the medical care or accept the inevitable course of the disease” (⁴). Current legislations allow medical interventions be performed regardless of consent only in case of obvious life threats and in unconscious patients.

As the abovementioned patient declared that they refuse to receive blood transfusion since she was one of the Jehovah's Witnesses no transfusion of blood or its byproducts has been undertaken. This treatment modality was mandated by the patient herself who had maintained intact consciousness at the moment. The responsible physicians adopted this strategy with respect to medicolegal limitations. However, this mode of action might also have been hazardous to the patient. For example, we have seen that the hemoglobin concentration was measured as low as 5.6 gr/dl, a level that might have bad consequences. We can only attribute the fair prognosis of this unique patient to her good luck and timely intervention.

The religious community Jehovah's Witnesses was founded in 1870. They hold that blood transfusion is against God's law. Surgical treatment of a Jehovah's Witness is a great challenge for every physician, especially those who confronts the challenge of acute injuries. Several case series were published on the drawbacks of operations on Jehovah's Witnesses and how to handle these (₁₄). In addition, oncological cases refusing transfusion due to the same reason were also cited (₁₅). Vogt et al reported a pediatric case with serious burn injury resulting in a severe decrease in hemoglobin levels (⁵). The surgical team employed a combined approach including erythropoietine and blood-saving surgical techniques, thus minimized blood loss and avoided blood transfusion.

In a retrospective review of three years by Victorino et al five patients out of 58 Jehovah's Witnesses with trauma were admitted due to penetrating trauma (⁶). One death and six complications occurred, though none were attributed to acute blood loss. Twenty-one patients refused blood transfusion absolutely while files of 33 did not include documentation of consent. The authors advocated documenting religious status and beliefs about blood transfusion while evaluating special treatment options for this unique trauma population.

To solve this ethical and medicolegal challenge faced in case the patient rejects to be treated in some way, legal regulations need to be deemed in order that the healthcare personnel would not be subject to execution. Laws should also include clear-cut definitions of the right to refuse treatment. Thus a definite approach of the medical community would be useful in not only cases like Jehovah's Witnesses, but also in facing demands of hunger strikes which represent an ethical challenge for physicians allover the world.

Correspondence to

Özgür KARCIOGLU, MD. Dokuz Eylül University Medical School, Emergency Department, 35340, Inciralti, IZMIR, TURKEY. e-mail: ozgur.karcioglu@deu.edu.tr Tel: +90.232.2383275 (home) +90.232.2595959 ext.2731 (hospital) Fax: +90.232.2599723